2835
American Cancer Society Lymphedema Workshop
The Physical Treatment of Upper Limb Edema
Oliver Leduc, P.T.1
Albert Leduc, Ph.D.1
Pierre Bourgeois, M.D.2
Jean-Paul Belgrado, P.T.1
1
Academic Department, Physical Therapy, Univer-
sity of Brussels, Brussels, Belgium.
2
Nuclear Medicine Service, St. Pierre Hospital,
Brussels, Belgium.
Presented at the American Cancer Society
Lymphedema Workshop, New York, New York,
February 20 22, 1998.
Address for reprints: Oliver Leduc, P.T., Service de
Kinesitherapie et Readaptation, C.P. 168, 50 Ave-
nue F.D. Roosevelt, 1050 Brussels, Belgium.
Received July 2, 1998; accepted August 20, 1998.
1998 American Cancer Society
Supplement to Cancer
BACKGROUND. Edema of the upper limb, without any doubt, constitutes the most
invalidating complication of breast carcinoma treatment. The swelling of the limb
results from decreased liquid evacuation by surgical intervention at the axillary
level and also by the eventual treatment by cobaltotherapy.
METHOD. The physical treatment for edema of the limb consists of a combination
of therapies that were tested for their effectiveness in laboratories on healthy
students and also on patients who underwent surgery for breast carcinoma. The
treatment consists of the application of manual lymphatic drainage (type Leduc),
the use of multilayered bandages, and the use of intermittent pneumatic compres-
sion. The population studied was represented by 220 patients who underwent
breast surgery. The authors followed their evolution during the first 2 weeks of
treatment. Patients were not hospitalized. The edema was measured by using
marks tattooed on the skin.
RESULTS. The limb that developed edema was compared with the healthy limb.
The most important reduction was obtained in the first week. The decrease was
equivalent to 50% of the average of the difference between both upper limbs.
During the second week, the results obtained stabilized; however, there was a slight
decrease at the end of the second week.
CONCLUSIONS. The physical treatment of edema represents the preferred thera-
peutic approach. However, it must answer to well-defined criteria to be efficient
and for long-lasting effects. The physical treatment is used to treat outpatients,
allowing them to follow a normal lifestyle. Cancer 1998;83:28359.
1998 American Cancer Society.
KEYWORDS: physical treatment, edema, breast carcinoma, manual lymphatic drain-
age, pneumatic compression, upper extremities.
L ymphedema is characterized by the concentration of proteins
caused by various physiopathological processes and, especially,
by the lowering of protein resorption. So long as the proteins
stagnate in the interstitial spaces, the osmotic pressure remains at
a high level, and the edema is maintained. This is quite disturbing,
because the protein concentration will favor the fibrous organiza-
tion of the edema and will act as a stimulus, causing chronic
inflammatory processes. Physical therapeutic treatment is the ap-
propriate technique for treating edema of the upper limb. Experi-
ence has proven that the physical techniques we use are not
limited to symptomatic treatment of the disease but, in many ways,
are the most curative treatments.1
Even if we insist on the necessity of an accurate diagnosis, treat-
ment, on the other hand, is initiated based on clinical signs. These signs
plus the anamnesis of the edema provide sufficient information to allow
the expert practitioner to change or vary the physical treatment.
We will restrict ourselves to discuss only the physical tech-
niques that are most appropriate in relation to insufficient drain-
2836 CANCER Supplement December 15, 1998 / Volume 83 / Number 12
age of the upper limb. The conservative (or physical)
treatment is not at all contradictory to the surgical
treatment: it is the first step in treatment, whereas
surgery is the final step.2 Conservative treatment
can be prescribed from the first signs of edema.
MATERIALS AND METHODS
Manual Drainage
Every treatment by manual lymphatic drainage (MLD)
is adjusted to the individual patient. The rules we
outline are a guide to proper treatment. Essentially,
the therapy depends on the particular reaction of the
edema in each patient. The absolute rule not to be
broken is this: The manipulation must always be very
superficial and extremely soft.3 MLD is effective only if
there are still some lymphatics left, so that they can be
activated,4 and an appearance or an increase of infil-
tration can be stopped.
MLD itself rarely is sufficient to evacuate edema.
Thirty years of experience have shown that improve-
ment can be maintained over the years if certain pre-
cautions are taken (i.e., prophylaxy of edema). MLD is
applied without any other technique when the volume
of edema is very restricted during the first period of
edema formation.
Generally, MLD will be only a part of the total
FIGURE 1. Photographs of the cotton
tube stretch and latex bandage (left) and
the low-stretch bandage (right).
edema treatment. Our experiments demonstrate that
MLD stimulates the resorption of proteins.4 This way
MLD is part of the global therapeutic approach, as
described below.
Intermittent Pneumatic Pressure
Our experiments have shown that pressotherapy es-
sentially influences the resorption of fluids, but rarely,
if at all, does it affect the resorption of proteins.57
Pressotherapy alone should never be used, but it is
always used in conjunction with MLD. The pressure
exerted never exceeds 40 mm Hg: Lymphatics collapse
with pressure that is any greater.3 Manual and me-
chanical pressure depends on the physiological con-
ditions of the evacuation by stimulation of the still
existing lymphatics. Intermittent pneumatic pressure
(IPT) is applied for 1 hour.
Multilayered Bandages
The bandages used in the treatment of lymphedema
(see Fig. 1) behave as a nonelastic envelope. Muscle
contractions cause pressure in the limb, and the inner
pressure varies as a result of changes in volume re-
lated to the contraction intensity.8 If we apply a rigid
bandage around the limb, then the effect of the con-
tractions will increase considerably in the limb.8

There is probably some relation between the ef-
fect of the pressure and the mechanical quality of the
dressing. Thus, a nonelastic tissue that is resistant to
stretching during muscle contraction undoubtedly
will receive higher pressure than an elastic tissue that
allows stretching.
The massage effect can be defined as the differ-
ence between maximum and minimum pressure val-
ues at the borderline of skin and bandages during
muscle activity.8,9 We studied several bandages in lab-
oratory situations on simulated limbs as well as on
patients. Superposition of several bandages, as in the
case of multilayered bandages (MLB), results, at the
borderline of skin and bandages, in pressures lower
than when the normal elastic bandages are used.9 The
use of MLB increases the lymph flow.10 Isodynamic
muscle contraction under MLB results in a significant
increase in the resorption of the edema. These exper-
iments all involved the upper limbs.
A cotton tube stretch bandage embraces the limb,
protecting the skin against full contact with the latex
bandage (Fig. 1, left; type Komprex Binde; Lohmann).
The latex bandage is placed so that it is half-covering
the limb without any tension. The nonelastic ban-
dages (Durelast; Lohmann) also are applied on the
limb from the distal region toward the proximal region
(Fig. 1, right). Note that we used several bandages, so
that we could apply them in a criss-cross pattern to
provide axial rotation of the whole MLB. The applica-
tion of the MLB ended proximally.
Measurements
We used tattooed reference markings on the patients
skin. These markings were localized at 20, 30, 40, 50,
and 60 cm from the distal extremity of the middle
finger. Perimeter measurements were taken before
each treatment during the first 2 weeks.
The patients were treated five times per week.
Each treatment lasted 2 hours. Measurements were
taken on the side of the edema and on the healthy
side. The different values for each limb were totaled
and then divided by the number of measures (5 mea-
sures). The averages of the difference between the 2
values were compared (Fig. 2). This statistical study
was limited to the first 2 weeks of treatment (10 treat-
ments): The treatment during these 2 weeks was fol-
lowed by another treatment in which the permanent,
custom-made sleeve replaced the MLBs.
Population
The population consisted of 220 women who under-
went surgery for breast carcinoma (one breast). The
patients ages ranged from 35 to 77 years. The patients
were not hospitalized and they led normal, everyday
Treatment of Upper Limb Edema/Leduc et al. 2837
FIGURE 2. Average of the difference between healthy arm and edematous
arm.
lives. Follow-up was organized over several months
and even several years. However, the statistical study
was limited to the first 2 weeks of physical treatment.
No medicine had been administered to the study pop-
ulation.
RESULTS
The most important reduction in the edematous limb
was registered during the first treatment week and,
more specifically, on the second day (Fig. 2). This
important decrease between the first and second
treatment undoubtedly is the result of massive elimi-
nation of fluids by the veins. This hypothesis is con-
firmed by the fact that patients who present with heart
failure withstand a little more difficulty on this first
day treatment. The reduction observed at the end of
the second week (10th treatment), compared with the
fifth treatment, is significant but is relative to the
results obtained (Fig. 3a c). It is at this time that we
modified the treatment by replacing the MLB with a
custom-made, low-stretch elastic sleeve.
CONCLUSIONS
The measurements obtained from the first treatment
show a very important reaction of the edema in asso-
ciation with these different therapeutic approaches
used simultaneously. This first therapeutic step is fol-
lowed by another during which the MLB is replaced by
a custom-made sleeve. This sleeve, at first, is worn day
and night and then only during the day. On the other
hand, the MLD and IPT treatment is administrated
five times weekly and diminishes progressively to
twice weekly, then once weekly, and finally is discon-
tinued. Certain patients are treated once more after
several months, once a week, to maintain results (Fig.
3d). In the majority of cases, the treatment can be
interrupted after a progressive decrease of the treat-
ment frequency. However, we must take into consid-
eration that, in accordance with the handicap gravity
2838 CANCER Supplement December 15, 1998 / Volume 83 / Number 12

FIGURE 3. Photographs showing edema of the upper limb postmastectomy in one patient before treatment (a), after 6 days (b), after 10 days (c), and after 7
months (d).

of drainage (veinous and lymphatic), certain patients Finally, results show that the edema has never totally
will have to undergo treatment for several months to disappeared. It is exceptional to reduce the edema
maintain the results acquired during the first 2 weeks. entirely and to return the treated limb to its healthy

FIGURE 4. Photographs showing the upper limb after axillar adenectomy in a male patient with breast carcinoma before (a) and at the end of (b) treatment.
state aspect (Fig. 4a,b). Generally, upper limb edema is
reduced significantly, but a difference in the two limbs
remains noticeable when both limbs are placed side
by side. One of the essential aspects of the therapy is
that the patients studied have not received any med-
ication, and none of them has been hospitalized for
physical treatment. This physical therapeutic ap-
proach allows the patients to be treated while bene-
fiting from a normal professional, social, and family
lifestyle.
REFERENCES
1. Leduc A, Caplan I, Lievens P, Leduc O. Le traitement phy-
sique de loedeme du bras. In: Monographies de Bois-Larris.
Paris: Masson, 1991.
2. International Society of Lymphology Executive Committee.
The diagnosis and treatment of peripheral lymphedema
[consensus document]. Lymphology 1995;28:1137.
3. Eliska O, Eliskova M. Are peripheral lymphatics damaged
by high pressure manual massage? Lymphology 1995;2:
2130.
4. Leduc O, Bourgeois P, Leduc A. Manual of lymphatic drain-
age: scintigraphic demonstration of its efficacy on collodal
protein reabsorption. In: Progress in lymphology IX. Ex-
cerpta medica. Partsh, editor. Amsterdam: Elsevier, 1988.
Treatment of Upper Limb Edema/Leduc et al. 2839
5. Leduc A, Bourgeois P, Bastin R. Lymphatic resorption of
proteins and pressotherapies. Vieme Congres group. Eu-
ropeen de Lymphologie (G.E.L.). Porto 1985;31:5.
6. Leduc O, Dereppe H, Hoylaerts M, Renard M, Bernard R.
Hemodynamic effects of pressotherapy. In: Progress in lym-
phology XII. Excerpta medica. Nishi, et al., editors. Amster-
dam: Elsevier, 1990:431 4.
7. Partsch H, Mastbeck G, Leitner G. Experimental investiga-
tions on the effect of a pressure wave massage apparatus
(Lympha Press) In: Lymphedema, Phlebologie und prok-
tologie. 1980.
8. Leduc O, Klein P, Demaret P, Belgrado JP. Dynamic pressure
under bandages with different stiffness. Vasc Med 1993;
466 8.
9. Demeyer D, Klein P, Vandeput D, Leduc A, Demaret P.
Etude comparative du comportement de bandages elas-
tiques et non-elastiques utilises dans le traitement de
loedeme lymphatique. Ann Kinesitherapie (Paris) 1988;15:
4617.
10. Leduc O, Peeters A, Bourgeois P. Bandages. Scintigraphic
demonstration of its efficacy on collodal protein reabsorp-
tion during muscle activity. In: Progress in lymphology XII.
Excerpta medica. Nishi, et al., editors. Amsterdam: Elsevier,
1990:4213.
11. Mislin H. Experimenteller Nachtweiss der Autochtonen Au-
tomatic der Lymphgefasse. Experientia 1961;17:29 32.
12. Leduc A. Le drainage lymphatique. Paris: Masson, 1980.